Addressing Usability Concerns in Oncology Electronic Health Records

Orlando, FL—Trends in the adoption of electronic health records (EHRs) show increasing use of advanced functionality. More providers are now using more advanced EHRs that include electronic clinical information and computerized entry of provider orders, as well as results management and decision support. However, according to Michael J. Hassett, MD, MPH, Assistant Professor of Medicine, Harvard Medical School, and Medical Director, Clinical Information Services, Dana-Farber Cancer Institute, Boston, MA, physicians are spending too much of their time working in inefficient EHR systems.

The results of a study that examined allocation of physician time in an ambulatory practice showed that physicians were spending the majority (48%) of their time doing work in the EHR or some other kind of desk work, compared with only 32% of their time in direct clinical contact. A productivity analysis of emergency department physicians found similar numbers: physicians were spending 44% of their time on data entry, compared with 28% in direct patient care, with the number of mouse clicks necessary during a busy 10-hour shift found to be approximately 4000.

Dr Hassett counted his own clicks during a recent clinic visit.

“To document an office encounter, I stopped counting after I got to 60 clicks. This highlights that a lot of the effort we’re spending with EHRs is in physician documentation,” he said.

Poor Usability in EHRs

Excessive time spent working in EHRs has affected the way in which physicians view these systems, Dr Hassett said at the American Society of Clinical Oncology 2017 Quality Care Symposium. In a 2014 survey of members of the American Medical Association, the American College of Physicians, and the American Academy of Family Physicians, 42% of physicians said use of their system did not improve efficiency, and 72% said their system did not decrease workload.

According to Dr Hassett, a “usable” system is easy to use and effective. The Healthcare Information and Management Systems Society defines a usable healthcare system as simple, natural (ie, automatically familiar and easy to use), and consistent. It should minimize cognitive load, promote efficient interactions by minimizing the steps needed to complete a task, and provide feedback so users are informed about the effects of the actions they are about to take.

EHR systems should also “forgive” users, by allowing them to discover through exploration without fear of disastrous results. A usable system should also employ effective language with terminology that is familiar and meaningful to the user, present readable information, and preserve content by minimizing screen changes and visual interruptions during task completion, he added.

Challenges to Usability
in Oncology

If systems are usable, then they are efficient and safe, but challenges to usability are frequently encountered in the oncology space, he said. Structured data entry is frequent, repetitive, overspecified, and inconsistent, and information visualizations are dense and incomplete. Similar tasks cannot only look different within and between applications, but also have different meanings. Finally, excessive alerts can result in alert fatigue, leading users to ignore important messages.

Creating a usable system can be a challenge because so much more information is being generated now than in the past. Healthcare problems, and the information they generate, are increasingly complex, and multidisciplinary teams are expanding, increasing the need for communication and interoperability. More people are using EHRs, including physicians, nurses, social workers, home health providers, billing compliance staff, and even patients, and more regulatory and contractual requirements are being introduced.

“Many different users working in different contexts with different content make it hard to create one EHR that works for everyone,” Dr Hassett said.

Addressing Dissatisfaction

From a provider perspective, Dr Hassett suggests making better use of the tools that EHRs offer.

“Through training and customization, I believe we can get more out of our EHRs and make them more useful, but it takes time,” he said. Supporting multiple modes of data entry is going to become more important in the future, as well as employing support staff and increasing patient engagement in reviewing and documenting data.

“One of the biggest tasks we do is order chemotherapy, but it’s a complicated process,” he said. Simple, consistent, intuitive, and efficient entry of chemotherapy orders should be based on widely accepted standards, and EHR systems should make it clear how to change orders and see how they have been modified from the standard and altered over time.

Dr Hassett suggested that developers of EHR systems work on bringing together and effectively displaying information that is relevant for users given their specific context, and standardizing terminology and enabling interoperability. They should also facilitate the efficient, nonduplicative capture of relevant structured data, and do a better job of automatically converting unstructured data to structured data. Finally, EHRs should support and enable the collection of outcomes relevant to a patient’s cancer with as much automation as possible, he concluded.